Total Call Backgroud Release form copy 2 (PDF)

BACKGROUND CHECK AUTHORIZATION / RELEASE FORM
I hereby authorize Total Call Mobile, Inc. (“TCM”) and its designated agents and representatives to
conduct a comprehensive review of my background. I understand that this background check does not
create an employment relationship between me and TCM. I understand that the scope of the background
check may include, but is not limited to, the following areas: Verification of social security number;
current and previous residences; employment history including all personnel files; education including
transcripts; character references; criminal history records from any criminal justice agency in any or
all federal, state, county jurisdictions; birth records; motor vehicle records to include traffic citations
and registration; and any other public records or to conduct interviews with third parties relative to my
character, employment history, and/or general reputation.
I further authorize any individual, company, firm, corporation, or public agency (including the Social
Security Administration and law enforcement agencies) to divulge any and all information, verbal or
written, pertaining to me to Total Call Mobile, Inc. or its agents. I further authorize the complete release
of any records or data pertaining to me which the individual, company, firm, corporation, or public
agency may have, to include information or data received from other sources. I hereby release Total Call
Mobile, Inc., the Social Security Administration, and its agents, officials, representatives, or assigned
agencies, including officers, employees, or related personnel both individually and collectively, from any
and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or
associates because of compliance with this authorization and request to release. You may contact me as
indicated below. I understand this authorization automatically expires 90 days from the date executed
below and that I have the right to revoke the authorization at any time, provided I do so in writing. I also
understand that, based upon the results of my background check, I may be prohibited from being a Total
Call Mobile Lifeline Sales Representative, which is a decision that shall be in TCM’s sole discretion.
Print Name:
(First)

(Middle)

(Last)

(Maiden)

(Mo/Yr)

(Street)

(City)

(State/Zip)

(Mo/Yr)

(Street)

(City)

(State/Zip)

Former Name(s) and Dates Used:
Current Address Since:

Previous Address From:

Social Security Number:

Date of Birth:

Telephone number:

Gender: Male / Female

Drivers’ License Number/State:
Signature:
Date:
------------------------------------------------------------------------------------------------------------------------------For Company Use Only: Status _____________________
Authorized by _____________________
CGM User Name: _____________________
1411 W. 190th St., Suite 700 y Gardena, CA 90248
Office 213.995.9700 y Fax 800.710.0963
www.totalcallmobile.com